Armed With Reason: The Podcast - Episode 30
The present and future of hospital-based violence intervention programs
This new podcast is an informative and hopeful talk with Dr. Kyle Fischer, Policy Director for the Health Alliance for Violence Intervention (HAVI). Dr. Fischer goes over the recent advances in hospital-based violence intervention, the positive influence of increased funding for such initiatives over the last few years, the worries as that funding dries up, and what we’ve learned from the expanding practices of helping victims of violence once they leave the emergency room.
We can help folks that have been affected by community violence using health-based approaches, and avoid some of these Second Amendment disagreements where a lot of places in the country can get bogged down in that without getting work done.
You can listen to the podcast via our channel on Spotify as well as watch on YouTube, or read the transcription below.
PODCAST TRANSCRIPTION:
Caitlin: Hello, everyone. Thanks for joining us here on the Armed With Reason podcast brought to you by GVPedia. Today we're joined by guest Dr. Kyle Fischer. Kyle serves as the Policy Director for The HAVI — which stands for the Health Alliance for Violence Intervention. He leads the organization coordinating, developing, and advocating for evidence informed policy to end community violence.
In addition to this role, he continues to practice as an emergency physician and fellowship director in health policy with the University of Maryland School of Medicine. His interest in violence prevention stems from his emergency medicine residency in Philadelphia, where he volunteered with the Healing Hurt People program. Dr. Fisher has health policy experience with nonprofit organizations and state and federal legislatures, including Wisconsin, Maryland, and the United States House of Representatives. He received a combined M.D./M.P.H. from the University of Wisconsin. Currently, he works clinically at the University of Maryland Medical Center. Kyle, thanks so much for joining me and Devin here today on the podcast.
Kyle: Thank you both for having me. I appreciate the opportunity.
Caitlin: Absolutely. So before we get into the work that HAVI does, as well as hospital-based violence interruption programs more broadly, can you tell us a little bit about what brought you into doing this work?
Kyle: Yeah, I'm happy to. So I grew up in the Midwest, in Wisconsin. And, you know, like a lot of folks in this state, lot of outdoorsmen and hunters, you know, firearms in the home, mainly, you know, rifles and shotguns and things like that for hunting deer mostly. And so, you know, growing up around firearms was not an atypical thing for me. Pretty standard, normal.
I finished medical school and I moved to Philadelphia. And I began taking care of these predominantly young black and brown men that were victims of gunshot wounds. And I had a few moments that have stuck with me to this day that really keeps driving me in this work. And one in particular was in my senior year of residency I was working an overnight shift in the emergency department at the old Hahnemann Hospital, before it closed down. And one of the security guards grabbed me and said, "Hey, doc, there's there's a car in the ambulance bay. And they said that there's a kid in there that got shot." And so I run out, and I look, and there's this old kind of beat up Toyota Corolla, and it's very dark. And all I could see was kind of the light glistening off of this blood on this kid's abdomen. And he was too scared to get out of the car. It just stuck with me. He didn't want to get out because he was scared.
And so we got the whole team to pull this kid out of the car, get him into the trauma bay, off to C.T. scanners and the operating room and all that stuff. And then, as it usually happens in medicine, after I leave my shift and I'm walking home, I start thinking more about this kid. And the next morning, I think to myself, I wonder what happened. Let me see. Let me check the Philly Inquirer and see what the story is about what led to this terrible shooting. And to my surprise at the time, of course, there was nothing written about him. There was no story. And I started doing this with my patients that came in — and routinely there is nothing written about them.
And it just cemented to me that, you know, if society isn't even paying attention to my patients, they certainly aren't looking for solutions. And so someone's got to have their back. And me as a doc, if I'm not advocating for my patients, what am I doing? And so I've really been in the anti-violence fight ever since, and continue to do the work.
Armed with Reason: The Podcast - Episode 22 - Reporting on inner city gun violence solutions, with NYC-based journalist Josiah Bates
Caitlin: Yeah, I would imagine seeing those types of situations, especially coming from the Midwest, that's a big change too, to Philadelphia. Unfortunately, we know which is a place where especially in the city proper, there is a lot of gun violence. And what you said about things not being reported in the media, that's another topic that we discuss here, too, right? Why certain things are covered, but certain things aren't covered. What responsible journalism looks like in gun violence prevention, and all of that is intertwined. So... Can you tell our listeners what hospital-based violence interruption programs are? How do they work, and what is your role in this space?
Kyle: Yeah, I'd love to. So a hospital-based violence intervention program — or HVIPs, as we tend to abbreviate it — is a comprehensive system of care to help folks that have been injured by firearm violence, to recover and make a full physical, psychological, and social recovery. And big picture goals going beyond just preventing repeat injuries or retaliation, but to make sure that we're transforming people's life courses, and going so much further. I think a lot of folks will ask, "Hey, why do you focus on people that have been injured already? Isn't that too late?" And what I like to respond is, it actually is the perfect opportunity. And with, I apologize. I need a drink of water....
Caitlin: No worries at all.
Kyle: ...So the reason that we focus on folks that have been violently injured is two reasons, actually. So one is we know that in the field of community violence intervention, you really need to focus your efforts on the folks that not are just at risk or even at high risk, but are at the highest risk. And when you look at the data, one of the biggest factors for someone's chances of being shot is if they've ever been shot before. And so we know that when someone comes into the hospital, they've been injured, that already is like a flashing warning light that this is someone that really does need the support of HVIPs, or community violence prevention program.
But the second is that we also know that in that moment that people are shot, it is a life transforming moment for them and people. It's called the kind of golden moment of opportunity where folks are looking towards the next steps and what happens now. And it's a perfect opportunity where people are receptive towards receiving resources of life advice and mentorship, and looking at that next phase. It's kind of analogous to when folks may have had a heart attack and they may be smokers. The research shows that that's one of the most common times in people's lives that they will quit smoking is when something happens that they're thinking about their own mortality and thinking about what's next. And we see that same type of phenomenon in violence prevention.
So how this looks like in practice is, in general, we call it a four-point step. So one is when someone's injured, immediately we look at scene safety and conflict resolution. A lot of times when someone's injured, maybe their friends or family members might come to the hospital and tempers flare. And you have to deal with this exact moment right now to make sure things are safe and steady. After that, we make sure that the patients really get high quality trauma-informed care both in the hospital and afterwards. Third, we do a comprehensive needs assessment to figure out what do the patients say that they need to heal physically, psychologically, and socially. And it's one of those things where until you start asking people what matters most in their life towards their recovery, you could never possibly guess what the items are on it. It ranges from everything from their immediate medical needs to, you know, getting a job, getting back in school, or you name it. People's lives are complicated.
And then after that, we really work on addressing those items on that needs assessment, and working upstream to address the social drivers of how could we do that past hospital discharge for 6, 12 months, however long patients need to make sure that they feel like they have achieved safety and are in a good place.
Devin: Yeah. And that in a way sounds like a lot of things that don't necessarily spring to mind when people think, Oh, I go to the hospital, they give me the medication or surgery, and then the next time you hear from them is in four weeks or so when the bill comes due, this sort of thing. And that's also a lot of activities that doctors themselves might not be the best at almost, where like it's a lot of community engagement and conflict management. Whereas like a surgeon is going to be specifically trained to stop the bleeding here and now and almost not what comes after. So is there a lot more infrastructure that the hospital builds on, or is it like an other organization that partners with the hospitals? How does that kind of function?
Kyle: Yeah, that is a perfect question. And I think you really teed up the most important part of our intervention that somehow I just left out is that we really leverage all of the resources that hospitals have, right? So hospitals have case managers, and social workers, and psychologists, and all those different folks. But we also bring in and make sure that we are hiring credible messengers that are the most important member of the team. These are folks that frequently have survived gunshot wounds themselves, or at least are from the communities that serve. And they really are the main drivers and engines of the programs.
One of our great trauma surgeons in our network has this thing that she likes to say. So she's a board certified trauma surgeon. People in medicine see her as the top of the top. And she will frequently say, "Boy, you know what? I'm in surgery with someone that just got shot. All I can think to myself is that, gosh, I hope I can get this guy through surgery so that John can save his life." And being that credible messenger because, yeah sure, as a doctor, I can get someone through the initial injury, but their recovery oftentimes just gets harder once they're released from the hospital. And if you talk to folks that have been injured like this, almost uniformly they will tell you that the psychological recovery and the social recovery is more challenging than the physical side of things.
And so as teams that are running HVIPs, we make sure that the violence prevention professional or credible messenger, they are really centered and as really the most important members of the team. And then in addition to that, Devin to your question, by nature of the work, we form really strong bonds with community based organizations, and have great working relationships with nonprofits, and CVOs, and all of these other service providers in the places that we work. Because, you know, we're working with folks after their discharge for six months to a year.
But for all these different services that patients may need, you need to leverage what's out there in the community, and you need to have good relationships so that you're not just handing people a stack of paperwork and saying, Oh yeah, you need mental health services; here's a list of psychologists that say they're accepting patients. Because that doesn't work. You really need to have strong relationships so that you're walking side by side with patients as they're going on their healing journey.
Devin: And that actually perfectly leads into my next question, which is that, in recent years there's been a lot more focus nationally on the effectiveness of community violence interruption programs. And their funding did receive a substantial but still insufficient boost over the past couple of years due to federal legislation. Then some states have also added funding to these programs. So how do HVIPs feature in this landscape, which you kind of somewhat addressed? And then how do you interact with and collaborate with other community-led programs in terms of basically what does that sort of partnership look like?
Kyle: Yeah, that's a wonderful question. And we know that in order to reach the folks at the highest risk, like I mentioned, you need to meet people where they're at, right? And HVIPs we live in one space, and there are street outreach programs that live in community-based spaces. There are other programs in the Community Violence Intervention ecosystem that may have connection to the justice system. And so all of these different CVI models are complementary and need to work together. Right?
So it's part of the reason why we're part of something called the APS Initiative — the Coalition to Advance Public Safety — with our great partners at Cities United and the Community-Based Public Safety Collection, National Institute of Criminal Justice Reform. Because all these different models, they need to work together historically.
Unfortunately, there was this competition between service providers, right? And I think it was mostly due to just the fact that everyone was scrapping to survive. So when I was in, about ten years ago when I was doing my residency in Philadelphia, there were hospital-based programs, there were some community-based programs — and they were both applying for the same tiny group of funding. And when that happens that does not force people towards collaboration. It forces towards competition, right? And that is the opposite of what the field needs.
And fortunately that's changing and shifting across the country because some of the funding has increased both at the city level, the county level, state level, and the federal level. So it's improving, but there's more room to go, obviously. But as we're doing this, we know that getting everyone to work together and collaboratively is easier said than done. There's a lot of history that needs to be worked on. We're finding that in communities across the country it is critically important for a lot of these small community-based groups that have been doing this work for decades and saving lives and doing incredible work, despite the fact that some of them aren't getting any funding or just tiny amount of funding.
But getting the different groups together to first break bread and meet each other and come together and learn more about each other's work is really, really important. But also to start figuring out protocols and collaborative agreements and data sharing and sorting out how can we all take care of our clients together? Because we're all working in the same community, but maybe one group is in one part of town, one another, or maybe they overlap in certain areas and need to figure out how to work together.
And so a lot of this community-based work has become very important, and a lot of planning and coordination has been a big area of focus recently. And we see that it's having big dividends. You know, as we record this, in the place where I work in Baltimore, our community is seeing big decreases in violence this year. And this has been kind of one of the years where our community violence ecosystem has really has been built up over the last couple of years. And we're starting to see the results. And, you know, one of the best years in about a decade. So we know it works, but there's a lot of work that goes into it.
Devin: Yeah. And kind of one of the things that we published recently on our Substack was after the conference where we interacted, and it's definitely heartening to hear that there's a lot more focus on collaboration rather than like fighting each other over to the last scraps at the table there. Because over the past decade I've been in those like within the GVP space overall, that's been almost exactly the case where you have tiny organizations that are volunteer led fighting with major organizations and everywhere in between, just scrambling to get some sort of funding. And all of those efforts are important, but the pie is quite limited, and it's just been frustrating to see where if you just like share data like you need to have the academics along with the community violence interruption programs along with those who focus at the state house — all working in tandem to mutually support. But it's often seen as siloed spaces and it's like, Well that doesn't impact me. And it's like, well they all impact each other and everybody can learn something from everybody else in the space.
And so it's definitely good to see that the hospital violence interruption programs and community violence interruption programs are working in partnership and not at cross ends when it comes to funding. And kind of a question that comes up for me is a lot of it's focused on like the retaliatory cycles of violence. I'm curious what hospital violence interruption programs may do when it comes to like domestic violence, where you're not necessarily seeing somebody who's been shot, but is battered and can potentially help there; and also programs that help on suicide.
There is this study — I want to say like six, seven years ago — from I believe it was the Ford Health system, I think it was Michigan, where they did lethal means counseling and such with a cohort and reduced the number of suicides in that cohort all the way to zero for the period of several years by just recognizing that, hey, lethal means matter, don't have firearms with you. And just curious whether hospital violence interruption programs are doing something along those lines or it's really more of a tailored focus.
Kyle: Yeah. So we are tailored towards community violence. That said, anyone listening to this podcast knows that it's a false idea to say that trauma lives in one lane. It does not. And you know, it goes back to the old common phrase of hurt people hurt people, and healed people heal people. And so we know that all forms of violence are oftentimes connected in really complicated webs.
And so one of the benefits of having an HVIP in a hospital is having that extra lens to view the violence ,and to work with other people that are generally working on some of those other areas. So in most hospitals on the suicide side of things, the psychiatry and psychology departments are working on it. On the domestic violence, intimate partner violence side, in many communities across the country have developed what we call sexual assault forensic examiners, save for same nurses that assist with that, and also really incredible work with trauma recovery centers that have a lot of similarities with the core services to HVIPs, but have traditionally worked with more DV/IPD subsets.
And so one area that we can assist with is helping to be part of that community and to work together. Whereas someone before may have gotten referred to one program and maybe it wasn't as great of a fit. But now that it's more kind of a robust offerings, we can work together, and oftentimes take a more holistic approach.
Caitlin: What would you say are some of the biggest threats and pitfalls that hospital violence intervention programs face, and what are the best practices for overcoming those potential shortfalls?
Kyle: Yeah. So I think of it in two kind of ways. So the first the biggest threat I would say that keeps me up at night right now is that we are facing an upcoming funding cliff for the field. So over the last couple of years, we had a big expansion in violence intervention. So about six years ago or so, there was record high levels in the Crime Victims Fund, which is a lot of people know it as VOCA — victims of crime assistance. And a lot of HVIPs got started with that VOCA money like six years ago. But that federal fund that comes from — the dollars in it come from the prosecution of white collar financial crimes for the most part — has dropped precipitously. And so now we see we have these record level investments five, six years ago, and now that has kind of plummeted. And so making sure that that is one area that states shore up is a big concern.
But it's doubled with what was an even bigger investment through the American Rescue Plan Act at the start of the pandemic, which provided at this point about $2 billion with a B towards community violence intervention throughout the country. But that money is sunsetting now that the pandemic is over and states have really until the end of this year — so just another two months, depending on when people are listening to this — and they can allocate to spend the money past this year, but the money's got to be allocated soon. So that's a double funding cliff that we're facing at the same time, which makes me very nervous. It means that we need people to step up at every level that can — cities, counties, federal governments, state governments, philanthropy, you name it. We need people to step up the game, because at the end of the day, if you can't pay your frontline credible messengers a salary so they can put food on the table, then you can't run a program. And so we need the money to do this. So that's number one.
And then separately, kind of a pitfall that you mentioned is on the orders of setting up and starting a program. I think because community violence intervention has become more widely known, and we now have a Surgeon General's advisory declaring firearm injuries a public health crisis, more health systems and hospitals are taking notice and saying, Oh boy, there is something we can do. We can benefit our community and do this. But I do see a lot of hospitals, because they're so good at doing so many things, they think that this is something that they can take on, like other things that they've done in the past without realizing how big of a project it is; and realizing how technical and challenging the work is; and really needing to understand that there are right ways to do it and wrong ways to do it. And it's really important to get technical assistance and to be part of the violence prevention community to do it right.
And so that's a pitfall, I would say, is for folks that are coming into the field just to have the humility to acknowledge the things that you don't know and to seek assistance to make sure you do it right, because this is life or death work. If you screw it up, people die. And we've got to get it right.
Devin: Yeah, that does tend to be kind of like even more broadly is a thing that we see where it's like somebody coming into this space and be like, Oh I read three articles online, I know what everybody else is missing here, I've got this. And then a couple of years down the line, it's like, why didn't this work? It's like, well, you didn't listen to the people who have been in this for decades and decades and such beforehand.
Kyle: So actually the field is moving forward in that. It is much more user friendly for folks than it used to be. That doesn't mean it's easy. But, you know, for example, I launched — along with my great colleague, Dr. Joseph Richardson at the University of Maryland College Park — we were the co-founders of HVIP in Prince George's County, Maryland. And that was in roughly 2018 or so that we launched that. And at the time, the HAVI had not built out as much of our training and technical assistance programs that we offer now. And so when we launched it, we were going based on our knowledge of having been in the field, going to the annual conference for a long time, did the research. And because I was on the board of, at that time we were called the National Network of Hospital and Science Intervention Programs. You know, I could see and I had all of the other programs, you know, when they were applying to be members, their intake form, and needs assessment forms, and all sorts of different things that you would need to build a program I could take from here or there.
And fortunately now with our experience, we've developed a set of best practices and what we call our standards and indicators. And you can go online right now to thehavi.org and download our manual that lists these are all the core components of what is in the hospital-based violence intervention programs. And these are the dozens of indicators to know whether or not you're doing things right. That didn't used to exist. So now there are more things that are available to help programs out, to make sure they're doing the right.
Further Reading: Debunking CVI Myths: CVI Is Only Street Outreach
Devin: Yeah, that's incredibly important. And one of the things at GVPedia, we focus on disinformation. And I recall coming back into this space a decade ago just seeing false talking points being sent out there, and then having to dig and dig and dig to find what the accurate information was from a plethora of different sources. And it's a whole lot easier if it's all in one place for somebody to find. And speaking of disinformation, what are some of the biggest myths that you've encountered in your work, both about the programs themselves, but also from the patients that you're serving to some degree? What's the ecosystem of misinformation out there that you see?
Kyle: The number one piece of misinformation that I find incredibly damaging and painful, to be honest, is unfortunately, in the patients that we serve, there is a large number of folks out there, it's blame the victim. They have these ideas in their head that the victims of attempted homicide somehow caused their own injury, or they contributed to their own injury, or they did something that they are the ones at fault — despite the fact that they have nearly died and have suffered this tremendous trauma. In this victim blaming, it comes from misunderstanding, and racism, and harmful tropes. And it gets amplified by a lot of folks out there. It's harmful for the patients themselves, right?
In the small way, like I mentioned at the start, that their stories don't get shared by the newspaper. Right? The Philly Inquirer did not cover a lot of the patients that I took care of when they were shot. And if we're blaming the victims and we're not even talking about what's going on, we're not going to be looking for solutions. But it's also a moral injury and a moral failing to us as a society. It clearly shows that we are not valuing the lives of some communities that really need assistance; and are like every other community in America, they just are looking to take care of their family, and live with their friends, and live a productive and healthy American life, and are just seeking out the American dream like everyone else. But because of this demonization that oftentimes occurs, these resources aren't going to the folks that need it. And we really need to push back on that.
Caitlin: Yeah, with it being Domestic Violence Awareness Month right now when we're recording this, that is certainly something that has come up in a lot of our conversations with individuals who work in the field with survivors and survivors themselves. This inherent story of like, Well, why didn't you just leave? Or, if you had a gun to protect yourself, this wouldn't happen. Or, you know, fill in the rest here, right? The excuses are endless. But you're right. It's certainly, a disservice seems like an absolute understatement. But to take all of the trauma that that person and their family is experiencing and then put out — whether it's a direct statement or indirect that, "Hey, this is your fault" in some way, shape, or form — is tragic on so many levels and unacceptable.
Kyle: Absolutely. And it goes beyond just like big picture; policy things on like whether or not we prioritize victims of community violence; and it goes beyond the hurt towards the patients and the families and the disrespect towards the communities. There are just numerous ways that it insidiously harms the patients themselves.
So one example that I do like to highlight is, we have a system in our country called victims compensation. So this is the idea that if you're the victim of a crime, that you should not be responsible towards covering the costs of when someone violated your rights and committed a crime against you. You should not have to pay the medical bills or legal bills or lost work time.
By law, in every state in the country there is a victim's compensation system to assist survivors in this region. However, across the country in most states survivors of community violence are locked out of the system. And it usually comes down to the ways that those things that we were just talking about became embedded into state laws. Right? So you cannot have contributed towards your own victimization gets weaponized in ways that are not based in fact and exclude a lot of people. And there are 10,000 other traps. So this type of misinformation, it goes beyond those big things, and it hits our patients directly, and it hits their wallets too. And so it's insidious in more ways than you could even think until we start talking to victims.
Caitlin: Yes, absolutely. We'll put that on the short list of things to work on in our free time here. So can you let our listeners know where they can follow you, where they can learn more about your work? We certainly want to make sure that they can check in on what you're doing if they'd like.
Kyle: Yeah, please check out our website at www.thehavi.org. We have lots of resources on there. Our resources page is filling at the brim and getting to the point where we need to start remodeling things. So if you're looking for technical assistance, if you're looking for webinars, if you're looking for fact sheets, if you want to learn more about best practices and thehavi.org is really a one-stop shop with all sorts of different things that you can find to learn more about it no matter where you're coming from. If you're looking to start a program, if you're looking to learn about new programs, whatever you're looking for, odds are there's something on our website for you.
Caitlin: Fantastic. Any final thoughts you'd like to leave our listeners with today?
Kyle: So I think at the end of the day, what I want people to know about hospital-based violence intervention programs is that when we say that violence is a health issue treatable by public health principles, that HVIPs are a tangible way that we can accomplish this. It's not a slogan. It's not something that people are just saying because it's a catchy phrase. This is a tangible way that we can save the lives of folks in our communities, and we can do so in a not just bipartisan way, but a nonpartisan way. We can help folks that have been affected by community violence using health-based approaches, and avoid some of these Second Amendment disagreements where a lot of places in the country can get bogged down in that without getting work done. And so this is an area where we are finding common ground and inviting communities across the country to join us and help heal our communities.
Caitlin: Devin, any final thoughts before we wrap up?
Devin: Well we could probably go for another two hours.
Caitlin: Don't worry, listeners, we're not going to go for another two hours.
Devin: Just thank you so much for being here. And if there's more people at HAVI that would like to speak on their various roles in this, our doors are always open on the podcast and also the Armed with Reason Substack. So thank you so much.
Kyle: Wonderful. Thank you both for having me on here today, and I'm excited that we're all working to save lives together.
Caitlin: Yes, absolutely you are. The work that you do, not only as a doctor, but making sure that those who end up in your hospitals for physical injuries, that emotional injuries are addressed, and that prevention down the road is a big part of their life so that they don't find themselves in the same positions again. That's really amazing, and we appreciate you taking some time today to talk with us about all that fantastic work.
Kyle: Thank you.
Image courtesy of Kyle Fischer.